Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0218, written 8 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jun 2016 |
|---|---|
| Reference | 2016-0218 |
| Deceased | Gwendoline Clarke |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
H M Senior Coroner for Gloucestershire Ms Katy Skerrett Tel: 01452 305661 Fax: 01452 412618 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEIN : (i) Po Operations Directors, ADL plc., Harewood Court, 89 Harehills Lane, Leeds. LS7 4HA. (ii) David Behan, Chief Executive, Care Quality Commission, Citygate, Gallowgate, cam 4 ro Ma Head of Inspection for the South Region) CORONER | am Katy Skerrett, Senior Coroner for Gloucestershire. CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On the 2™ January 2015 | commenced an investigation into the death of Gwendoline Betty Clarke. The investigation concluded at the end of the inquest on the 7" June 2016. The conclusion of the inquest was an open conclusion and a narrative conclusion. The medical cause of death was 1A respiratory failure, sepsis, and pancreatitis in a woman with diabetes, 1B | bilateral femoral fractures. CIRCUMSTANCES OF THE DEATH Mrs Clarke “Betty” was an 89 year old lady who had a significant medical history including cerebral meningioma which was removed in 2011, diabetes, cerebrovascular disease, longstanding anxiety and depression, renal failure and chronic obstructive airways disease. She was a long term resident at Pine Trees Court Care home, Tuffley, Gloucester, having moved there in 2011. She had two admissions to hospital in August and October 2014 with chest related problems. She was able to mobilise using a walking aid and / or with assistance from carers. However her mobility was gradually deteriorating. On the 24" December she was on antibiotics for a chest infection. During the day on the 27" December 2014 she appeared her usual self. During the morning on Sunday 28" December Betty was complaining that she had leg pain and that a member of staff had hurt her. She made several members of staff aware of that fact. No medical review from a doctor was sought. Police were not informed. Emergency services were requested at approximately 21.45 hours. Paramedics arrived at 1.15am on the 29" December, and transferred Betty to hospital. She was admitted to hospital in the early hours of the morning on the 29" December 2014 having sustained injuries to her legs and chest, including multiple fractures. These injuries were caused by a significant incident probably occurring during the morning of the 28"" December 2014. The mechanical cause of these injuries whether due to a fall/ how she was handled by a carer remains unclear. It is more probable than not that a member of staff was aware that Betty had sustained a significant injury, and did not report that fact. Police were informed by hospital staff in the Accident and Emergency Department. After admission to hospital she subsequently deteriorated with clinical evidence of respiratory failure and sepsis. Her clinical deterioration was related to her underlying injuries. Her medical history made her more vulnerable to such a decline. She died at 06.43 hours on the 31° December 2014. CORONER’S CONCERNS Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | Fax 01452 412618 During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) No member of staff reported the injury that Betty sustained, and (2) No member of staff escalated Betty's allegations that a member of staff had hurt her until approximately 12 hours after she first made the allegation. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4pm 2" August 2016. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons, (i) a stepdaughter of Mrs Clarke, 11 Little Normans, Longlevens, Gloucestershire, GL2 OEH. (ii) Chief Constable, EE Gloucestershire Constabulary, County Police Headquarters, No1 Waterwells Drive, Waterwells, Quedgeley. Glos. GL2 2AN. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated 8” June 2016. Signature Ms K Skerrett Senior Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | Fax 01452 412618
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
PRIVATE & CONFIDENTIAL Pine Tree Court Response to Coroner’s Report 1) Introduction | | fespond to|the HM Clark who réfers to t bjlateral femoral fra ab follows: } B) A 12 hour de The lady concerned h Paranoia and there w. oroner’s Report dated 8.6.16 in relation to the death of Gwendoline Betty e cause of death as respiratory failure, sepsis, pancreatitis, diabetes and ures, The Coronet refers tg concerns in point 4 in order to prevent possible future deaths, the matters are A) Reporting of the injury that was sustained ay in escalation and safeguarding matters in relation to the allegations that a member of staff had hurt her. 2. Background and Key Facts ad a number of long term conditions including mental health issues resulting in as a history of regular accusations being made against staff as well as others. She also took medication that would of course affect the bone structure. | | Betty moved around|the home freely, she had suffered previous unwitnessed falls due to her level of independence. Pere is no reference that any staff were indeed aware of any falls or occurrences that could have esulted in Such injury, this was confirmed by the police investigation nor was there any person on duty that Betty had described who had allegedly caused the harm. The circumstances pa that there was a delay in requesting aid, a delay in the attendance of the Dossed whidetre a eriod when the offic Friday 8-5.30pm) heh = Actions nd delays in reporting the safeguarding matter at the weekend/bank holiday e was closed. This was clearly outside of these times (office hours Monday — ce the delay stated of 12 hours. An analysis|of the report and taking on board the concerns raised through the process, the following actions are/necessary: a Action t By Who/When Evaluation home staff a hours report Thié also inclu (RN) ng process and the manager absence, check staff awareness and knowledge of this process. i Re-enforce the safeguarding policy, share with all July 2016 Audit PU Within d use this as supervision, include out of August des an update of the Job Description screening fo } | If Include the jeri process under general PU ia Document | our clients, an assessment to determine | June 2016 those mor at risk of fractures due to medical problems and lack of sunlight Audit of Care Include relevant signs/symptoms within the monthly | | Plan health check i. check Quality File each month re use of | | accident log | [ii | Ré-enforcelthe home’s protocols for unwitnessed | Training Record | accidents ahd remind staff regarding examination, July 2016 Analysis ) clinical judgement and pain management — see enc _| pain chart viv Plan training and supervision refresher first aid j Certification particularly to focus on fracture detection 5.7.16 | Vv Review the|home’s management and on-call process Complete New registered ! both home|Manager and regional support manager manager — l have now rare ending | Vi intensify the abuse audit and surveys — to complete ma 1 check re | | each month for a 12 month period quality file _ compliance | vii Utilise the gompary escalation tool in order to Complete and to check } highlight the practise of the ambulance service Ongoing during care plan | particularlyin relation to handling techniques — check audit Sept 16 | use of SBA Il vii Conduct a reflective piece, include qualified staff and | Complete | hold on | use for NME revalidation June 2016 file and distribute to nurses (own | copy) ix Refer the issue for external investigation (Bob Taylor) | July 2016 Personnel file and review possible breeches in conduct as well as | NMC code _ |x Explore thelout of hours safeguarding service within June 2016 | Poster available | Gloucester and circulate details with the home
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